1366486763 NPI number — DETROIT MACOMB HOSPITAL CORPORATION

Table of content: (NPI 1366486763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366486763 NPI number — DETROIT MACOMB HOSPITAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DETROIT MACOMB HOSPITAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST. JOHN DETROIT RIVERVIEW HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366486763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7733 E JEFFERSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48214-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-499-4254
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7733 E JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48214-3707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-499-4254
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUNROE
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-499-4108

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AN820023 . This is a "MCARE CRNAS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7853578 . This is a "AETNA CRNAS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: AN820017 . This is a "MCARE ANESTHESIOLOGISTS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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